This inspection was unannounced and took place on the 5 November 2015. The inspection continued on the 6 November and 9 November 2015 and was announced. It was a planned comprehensive inspection carried out by two inspectors.
The service is registered to provide accommodation and residential or nursing care for up to 81 people. During the inspection there were 80 people living at the service. The home had three floors and all the rooms were single with an en suite facility of which 25 had fixed ceiling hoists. Each room had a fixed call bell and the system also enabled people to have a mobile call bell so that they could call for assistance wherever they were in the building. Each floor provided a different type of service. The ground floor provided residential care to people living with a dementia and had access into a secure garden. The first floor provided residential care and the top floor provided nursing care to older people.
Each floor had lounges and dining room areas with self- contained kitchenettes which staff and families used for making drinks and light snacks. There was a bathroom on each floor with specialist bathing facilities. A guest room was available for visitors who needed to stay overnight. On the ground floor there was a conservatory used mainly for quiet time. There were two lifts giving access to the first and top floor, a commercial laundry and kitchen facility. The service had a security door entry system in place and provided a receptionist service seven days a week until 8pm.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found the service to be safe. People told us that they felt safe living at Avon View. Staff had received safeguarding training as part of their induction and then every three years. We looked at training records that evidenced this and spoke with staff who demonstrated they understood how to protect people and keep them safe from harm. We saw safeguarding information displayed around the service which included who to contact if you had concerns.
People’s risk were assessed and reviewed at least monthly. Risks included malnutrition, eating and drinking, tissue viability and mobility. Care plans were in place for any risk that had been identified and explained actions to be taken to minimise the risk and keep the person safe. One person had fallen from their recliner chair which led to their falls risk being reviewed by an occupational therapist. The person was assessed as understanding the risk to their safety and had the freedom and choice to determine what restrictions were acceptable to them.
Records for the maintenance of equipment and the premises were up to date. Staff had received fire training and fire drill evacuation practice took place six monthly. Each person had a personal fire evacuation plan in place. The service had an emergency contingency plan which contained information on how the service would keep people safe in the event of a major incident which affected the running of the service.
We observed good staffing levels. People we spoke with told us that there were enough staff. Staff files contained evidence that recruitment practices were safe. Criminal record checks had been carried out prior to employment and had been reviewed three yearly.
People’s medicines were managed safely. However, the provider was in the process of making improvements to how temperatures of medicine storage areas were regulated and monitored. Refrigerators were operating within a safe range and the temperature monitoring records were being updated at the time of the inspection to allow appropriate temperature recording. A member of staff told us that some people had been getting morning medicines as late as 11am. The manager had taken actions so that senior staff supported when necessary. During our inspection people were receiving their medicines in a timely way.
New care staff completed the Care Certificate induction course, safeguarding and food hygiene training over their first days of employment. The Care Certificate is a national induction for people working in health and social care who have not already had relevant training. Staff had completed mandatory training such as moving and handling, infection control and health and safety and certificates were on their files. Specialist training had also been completed which was specific to people living at the service. Staff received regular supervision and had an annual appraisal.
All staff, including housekeeping and catering staff had received dementia training. In July 2015 a survey was carried out with health commissioners, staff, families and people living at the service. The survey looked at people’s views on how the environment, activities and staff training met the needs of people living with a dementia. The results of the survey had been used to create a ‘Dementia Development Plan’ with actions agreed to support improvement. The actions identified reflected people’s views and preferences on receiving support with their dementia.
Nursing staff received regular clinical training and supervision. Training included wound management, syringe driver, nutrition and end of life training. The service had achieved a ‘Gold Standard Framework (GSF) accreditation three years ago. The GSF is a national award. It is a model of care that enables good practice to be available to people nearing the end of their lives. The service was reassessed in October 2015 and received a higher level of accreditation.
People consented to their care, support and treatment. Mental capacity assessments had been carried out. Where it was assessed that the person lacked capacity to consent to the care arrangements a Deprivation of Liberty (DoLs) application had been sent to the local authority. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The manager and staff were aware of the DoLs legislation and how to apply it to their practice.
Some people had been assessed as being at a high risk of malnutrition. Staff were aware of who these people were and the actions needed to reduce the risk. Referrals had been made to health professionals to assess persons’ swallowing and their risk of choking. People had safe swallowing plans and these were being followed. For main meal times there were systems in place that provided a check that people got the food and drink they needed. No processes were in place for mid-morning and afternoon drinks and snacks which led to a person not getting regular drinks. We discussed this with the manager who told us that this would be reviewed immediately.
People had a choice of meals and where they would like to eat. We saw people enjoying meals with their families. The kitchen had records from the care staff that let them know of any special dietary requirements. Staff supported people discreetly and people enjoyed their meals in a relaxed environment.
People had access to a range of healthcare services including GP’s, specialist nurses, dieticians and palliative care specialists. Care files had good evidence of healthcare referrals.
We spoke with people, their relatives and professionals who visit the service who all gave us positive examples of how kind and caring they found the staff. We observed staff supporting people in a caring way. We looked at three files that contained comprehensive details of a person’s life history. We found that staff had a good knowledge of people’s families but in some cases a limited awareness of the person’s whole life history. Staff told us they were aware it was on file and would refer to if needed.
People told us they felt involved in decisions about their care. Information about advocacy services was available around the service.
People told us that they felt their privacy and dignity were respected. Staff were able to give us examples of how they maintain a person’s privacy and dignity. However two relatives we spoke with felt at times people’ dignity was not maintained. We saw good examples of staff treating people with dignity and respect however some practice we observed did not. We discussed this with the manager who told us she would look at introducing a dignity audit that took place more regularly would include observations of staff practice.
People and their families felt involved in planning their care and support. People were encouraged to personalise their rooms and a leaflet had been produced with the help of people living at Avon View and given to new people moving into the service.
Care plans were written for people and clearly detailed the personalised support people had agreed. Staff had a good knowledge of people’s risks and how to support them. Changes to a person’s health or wellbeing was responded to quickly. People had opportunities to increase and maintain their independence. Staff were observed supporting people in a way that maximised their level of independence. Activities were available seven days a week. Each person had their own copy of the weekly activities programme which provided the information in written and picture format. People were offered a range of activities including trips into the community. Staff supported people with keeping in touch with family and friends.
People, their relatives and staff all told us that they felt they had opportunities to feedback on the service and felt able to raise a complaint. Complaints were investigated appropriately and outcomes shared with staff. We were aware that there had been a complaint about a person’s experience during a short respite stay and that as a result additional checks by senior staff had been introduced. We looked at a care file for a person having respite care. They needed their catheter changed every 6-8 weeks. There was no evidence that the staff had identified and planned for the next catheter change. We spoke with a nurse who immediately addressed this. We saw minutes of meetings with people who live at the service and relative meetings. They were displayed around the service on noticeboards and in a folder in reception and included details of actions taken. Compliments were discussed at staff meetings and then displayed on the units.
We found the service was well led. Staff told us they felt happy and felt supported in their work. Staff told us that they felt able to raise questions about things they were unsure about and that this was encouraged by senior staff. We observed professional and relaxed interactions between staff and the management.
The home had an audit schedule that covered key areas of service. Feedback to staff had been provided constructively and had explained the service expectations and individual and/or team responsibilities.
The results of the quality assurance carried out in July 2015 provided positive feedback from other professionals, people who used the service and their families. However some people feedback that they felt their call bells were not being answered quick enough. A weekly audit had been introduced to monitor with a target of answering within three minutes.
People, their families, staff and other professionals were involved in developing the service. They were involved in a survey that looked at the environment, activities and staff training in relation to supporting people living with a dementia. The results had been used to create a ‘Dementia Development Plan’ which had been shared and was on display on notice boards.
The manager is working with a local University so that student nurses can have some of their training at Avon View. Nurses have completed a mentorship course in preparation for supporting student nurses with their training.
The manager had a good understanding of the Data Protection Act, Freedom of Information Act and her responsibilities for sharing information with CQC.